Differentiated Open Surgery for Traumatic Gunshot Arteriovenous Fistulas of the Lower Extremities

Objective. To develop and assess an algorithm for open surgery in patients with traumatic gunshot arteriovenous fistulas (AVFs). Material and methods. The early results of open surgery were retrospectively assessed in 60 wounded subjects with traumatic gunshot AVFs admitted to a level 5 rear military medical facility. All the wounded were men with an average age of 34.5±8.9 years. The individual management approach depended on the presence of acute complications of AVF, the location and width of the AVF, the presence of a false aneurysm of the main vessel, intraoperative findings, and the decision on which intervention to perform based on the morphology of the artery and vein samples. The intervention was performed in four consecutive steps: precise isolation of the AVF and the false aneurysm, AVF separation, repair of the artery, and repair of the vein. Results. Fifty-nine patients underwent surgery;. 6 (10%) interventions were emergent, 4 (6.8%) were urgent, 4 (6.8%) were delayed, and 45 (76.3%) were elective. The main artery was grafted with reversed autologous vein in the majority of cases (38 patients, 63.3%). Main veins were mostly ligated (51 patients, 88.5%). No deaths were registered. There was no need for secondary amputations. An additional revascularization procedure was required in 2 (3.4%) cases due to arrosive bleeding and thrombosis of the PTFE popliteal artery graft. Non-massive pulmonary embolism developed in 1 (1.7%) patient. Conclusion. Individualized management of traumatic gunshot AVFs of the lower extremities with a four-step open intervention is effective and safe.